How Is Methadone Prescribed

How Is Methadone Prescribed

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Even though the effects of methadone are different from those of other opioids, your body can still get used to it. This means you might need to take more to feel the same effects. This is called tolerance, and it can happen with any opioid. Your body can also become dependent on methadone and other opioids. Your brain relies on the pain relief they bring, and you have withdrawal symptoms if you stop taking them suddenly.

Methadone is an opioid, like heroin or opium. Methadone maintenance treatment has been used to treat opioid dependence since the 1950s.14 The opioid dependent patient takes a daily dose of methadone as a liquid or pill. This reduces their withdrawal symptoms and cravings for opioids.

Hong Kong has had a methadone maintenance treatment program since 1972. The program was started in response to rising levels of drug use. More recently, the program has been crucial to controlling the HIV epidemic. Hong Kong methadone clinics have several important characteristics that make them easy for drug users to access:

Research conducted with patients of the Hong Kong methadone program has shown that patients who attend the clinic regularly show reduced levels of drug injecting and HIV risk behaviours. It has also been shown that patients receiving methadone doses of greater than 60mg per day were less likely to use or inject drugs than patients receiving doses of less than 60mg per day.

MMT in closed settings reduces drug injecting by prisoners. In Australia, a trial of MMT in prison found that despite being in prison, over 80% of inmates starting methadone treatment had used heroin in the previous month; however, after four months of treatment, only 25% of prisoners were still using heroin.16 By reducing drug injecting, MMT reduces opportunities for HIV to be transmitted between prisoners.

Indonesia established a pilot methadone maintenance program in prison in 2005. The program was started as part of Indonesia's comprehensive HIV prevention strategy for prisons. Other components of the strategy include distributing condoms and bleach (for cleaning used needles and syringes) in prison and providing free antiretroviral treatment for HIV-positive prisoners.

Some of the patients in the methadone program are continuing treatment begun in the community, while others have started methadone treatment in prison. Patients who are HIV-positive receive free antiretroviral treatment in addition to methadone.

There are plans to expand the methadone maintenance program to other prisons in Indonesia. The success of this pilot program has demonstrated that it is feasible to introduce methadone maintenance treatment in resource-poor settings.

Only a medical doctor may prescribe methadone. A medical doctor should conduct the assessment on which the decision to prescribe methadone is based. Doctors also take part in treatment planning and treatment reviews.

Methadone should be dispensed via a medical clinic within the closed setting. The clinic must be staffed and open to patients seven days per week. The clinic should be equipped with a dispensing pump or measuring cylinder for ensuring accurate methadone dosing, and should also maintain adequate supplies of basic first aid and resuscitation equipment.

Following dosing, patients must move into a supervision room located next to or close to the medical clinic. This is to help prevent diversion of methadone to others. Patients in the supervision room must be monitored for around 15-20 minutes after dosing.

Onset of effects occurs 30 minutes after swallowing and peak effects are felt approximately three hours after swallowing. At first, the half-life (the length of time for which effects are felt) of methadone is approximately 15 hours; however, with repeated dosing, the half-life extends to approximately 24 hours. It can take between 3 and 10 days for the amount of methadone in the patient's system to stabilise.

Interactions between methadone and other drugs can lead to overdose or death. Drugs that depress the respiratory system (e.g. benzodiazepines) increase the effects of methadone. Drugs that affect metabolism can induce methadone withdrawal symptoms. Clinically important drug interactions are listed in Table 12 (p.83). In particular it is important to note interactions between methadone and medications used to treatment HIV and tuberculosis:

Patients receiving these medications, or other medications listed in Table 12, in combination with methadone should be monitored for signs of withdrawal or intoxication, and their methadone dose adjusted accordingly. See also AIDSinfo, , for up-to-date listings of antiretroviral medications and interactions with other drugs.

Patients in methadone maintenance treatment can become tolerant to the pain-relieving effects of opioids. In the event that an MMT patient requires pain relief, non-opioid analgesics such as paracetamol can be given. If methadone patients are provided with opioid analgesics, they may require higher than normal doses to experience pain relief.

Methadone maintenance treatment is indicated for patients who are dependent on opioids or have a history of opioid dependence. In closed settings, it is important to remember that patients not currently physically dependent on opioids can benefit from the relapse prevention effects of methadone maintenance treatment.

There are few risks associated with the long-term use of methadone. Methadone does not damage any of the major organs or systems of the body. There are few side effects of methadone and those that do occur are less harmful than the risks associated with illicit opioid use.

The major risk associated with methadone is overdose. Overdose is a particular concern in the initial stages of MMT and when methadone is used in combination with other depressant drugs. Methadone overdose may not be obvious for three to four hours after ingestion. Patients should be closely monitored during the first week of treatment for signs of overdose, including:

Overdose is more likely to occur if the patient is using other drugs that depress the central nervous system e.g. alcohol, benzodiazepines or opioids. Patients should be informed of the risks of using these drugs in combination with methadone.

In case of overdose, naloxone should be administered. This reverses the effects of methadone. Because methadone has a long half-life, it is necessary to provide a prolonged infusion or multiple doses of naloxone over several hours. Patients who have overdosed should be transferred to a hospital and monitored for at least four hours.

Methadone should be prescribed with caution to patients who are using other drugs, particularly those that depress the central nervous system (e.g. alcohol, benzodiazepines). Patients should be advised of the increased risk of overdose associated with using methadone in combination with other drugs.

The first dose of methadone given to a patient is low. The size of the dose is gradually increased until the maintenance dose is reached. The maintenance dose is the amount of methadone the patient requires to prevent opioid withdrawal symptoms, but does not induce euphoria.

The first dose of methadone should be between 10-30mg. Patients who have recently used opioids can be given a first dose at the higher end of this range. The first dose given to a patient who has not recently used opioids should be no greater than 10-20mg. When determining the size of the first dose, keep in mind that deaths from methadone overdose in the first two weeks of treatment have occurred at doses as low as 40-60mg per day.

Monitor the patient for signs of withdrawal and intoxication and adjust the methadone dose accordingly to find the patient's maintenance dose. This process may take several weeks. The maintenance dose will usually be between 60-120mg, but may be higher or lower, depending on the patient's history of opioid use. See also Figure 3.

If a patient is detained who has been on buprenorphine maintenance treatment in the community, you should endeavour to assist the patient to continue this treatment. However, if buprenorphine is not available, the patient should be transferred to methadone maintenance treatment (Figure 4).

Methadone is a medicine used to treat heroin dependence. It is taken daily to relieve heroin withdrawal symptoms and reduce cravings for heroin. The aim of methadone maintenance treatment is to help you reduce your illicit drug use. Before you begin methadone maintenance treatment, you should be aware of the following:

I, _____________________, have read (or have been read) the patient information sheet about methadone maintenance treatment. I have been offered the chance to ask questions about this treatment and am satisfi ed that I have the knowledge to make an informed decision about this treatment option.

Patients in methadone maintenance treatment must be dosed once every day. Methadone dosing must be strictly managed in order to minimise diversion. Diversion refers to patients giving or selling their methadone to others for other's use:

Accidentally dispensing too much methadone to a patient can result in a life-threatening situation. It may be three to four hours after dosing before the patient shows signs of overdose. In case of overdose:

Medical clinics dispensing methadone should maintain clear records of the amount of methadone dispensed each day, and the amount of methadone stored on the premises. Records should also be kept of accidental spillage of methadone. Discrepancies between the actual amount of methadone on the premises and the amount recorded as being on the premises should be investigated by an independent staff member.

Analysis of a patient's urine for evidence of illicit drug use is expensive and will not stop patents from using other drugs. Furthermore, results can be unreliable. There is no evidence that punishing patients for returning positive urine samples results in decreased illicit drug use. Urine drug screening should only be used for therapeutic purposes, for example, when a patient is suspected of using drugs and confirmation of this is required. This provides information that the doctor can use to identify if the patient's treatment needs are being met. For example, if a patient's urine sample shows continued heroin use despite being in MMT, it may be a sign that the patient needs a higher methadone dose. 2b1af7f3a8